SpineFITyoga.com

Author: chad reilly

  • Tennis Elbow: Both Concentric and Eccentric Exercise Helps

    A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy). Clin Rehabil. 2014 Mar 14. [Epub ahead of print] Peterson M, Butler S, Eriksson M, Svärdsudd K.

    Abstract
    Objective:To analyse treatment effects of eccentric vs. concentric graded exercise in chronic tennis elbow.Design:Randomized controlled trial.Setting:Primary care in Uppsala County, Sweden.Subjects:A total of 120 subjects with tennis elbow lasting more than three months were recruited from primary care and by advertisement.Intervention:Eccentric (n = 60) or concentric exercise (n = 60), by lowering or lifting a weight, at home daily, for three months with gradually increasing load.Main measures:Pain during muscle contraction and muscle elongation, as well as strength, was assessed at baseline and after one, two, three, six, and 12 months. Function and quality of life was assessed at baseline and after three, six and 12 months.Results:The eccentric exercise group had faster regression of pain, with an average of 10% higher responder rate at all levels of pain reduction, both during muscle contraction and elongation, (p < 0.0001 and p = 0.006, respectively). Significant differences were found in Cox’s analysis from two months onwards (HR 0.78, 95% confidence interval (CI) 0.63-0.96, p < 0.02). This represents an absolute pain reduction of 10% in the eccentric vs. the concentric group and a number-needed-to-treat of 10. The eccentric group also had a greater increase of muscle strength than the concentric (p < 0.02). The differences persisted throughout the follow-up period. There were no significant differences between the groups regarding function or quality of life measures.Conclusion:Eccentric graded exercise reduced pain and increased muscle strength in chronic tennis elbow more effectively than concentric graded exercise.

    Quotes from study:
    In conclusion , an exercise programme for chronic tennis elbow should be designed to gradually put load on the affected painful tissue, and stress the eccentric work phase, but need not exclude the concentric work phase.”

    My Comments:
    This is a great study, not because I need another blog on tendinopathy, but because it refutes some earlier tendinopathy research that found concentric exercise to be either worthless or aggravating. These researchers found both concentric (lifting a weight) and eccentric (lowering a weight) contractions to be beneficial, with eccentric exercises only being only about 10% better. This backs up my own physical therapy protocols where I make use of regular progressive resistance exercise (combining concentric and eccentric contractions). It also helps to explain why some more recent studies were heavy slow lifting with regular concentric and eccentric contractions are more effective than eccentric only contractions for the treatment of tendinopathy. The big downside of eccentric only contractions is not that they aren’t effective (as this and almost all studies show they are) but that they are tedious to both coach and perform as the patient has to lift the weight with their good arm and lower it with their bad arm.  Also, by using normal combined lifts in physical therapy, patients are learning an effective exercise they can continue indefinitely as part of their fitness program. By contrast, eccentric only exercises are more of a “specialty therapy exercise” that patients rarely would nor should wish to continue after their pain resolves.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Electric Muscle Stimulation for Athletes

    Electromyostimulation–a systematic review of the effects of different electromyostimulation methods on selected strength parameters in trained and elite athletes. J Strength Cond Res. 2012 Sep;26(9):2600-14. Filipovic A1, Kleinöder H, Dörmann U, Mester J.

    Abstract
    This is the first part of 2 studies that systematically review the current state of research and structure the results of selected electromyostimulation (EMS) studies in a way that makes accurate comparisons possible. This part will focus on the effects of EMS on strength enhancement. On the basis of these results, part 2 will deal with the influence of the training regimen and stimulation parameters on EMS training effectiveness to make recommendations for training control. Out of about 200 studies, 89 trials were selected according to predefined criteria: subject age (<35 years), subject health (unimpaired), EMS type (percutaneous stimulation), and study duration (>7 days). To evaluate these trials, we first defined appropriate categories according to the type of EMS (local or whole body) and type of muscle contraction (isometric, dynamic, isokinetic). Then, we established the most relevant strength parameters for high-performance sports: maximal strength, speed strength, power, jumping and sprinting ability. Unlike former reviews, this study differentiates between 3 categories of subjects based on their level of fitness (untrained subjects, trained subjects, and elite athletes) and on the types of EMS methods used (local, whole-body, combination). Special focus was on trained and elite athletes. Untrained athletes were investigated for comparison purposes. This scientific analysis revealed that EMS is effective for developing physical performance. After a stimulation period of 3-6 weeks, significant gains (p < 0.05) were shown in maximal strength (isometric Fmax +58.8%; dynamic Fmax +79.5%), speed strength (eccentric isokinetic Mmax +37.1%; concentric isokinetic Mmax + 41.3%; rate of force development + 74%; force impulse + 29%; vmax + 19%), and power (+67%). Developing these parameters increases vertical jump height by up to +25% (squat jump +21.4%, countermovement jump +19.2%, drop jump +12%) and improves sprint times by as much as -4.8% in trained and elite athletes. With regard to the level of fitness, the analysis shows that trained and elite athletes, despite their already high level of fitness, are able to significantly enhance their level of strength to same extent as is possible with untrained subjects. The EMS offers a promising alternative to traditional strength training for enhancing the strength parameters and motor abilities described above. Because of the clear-cut advantages in time management, especially when whole-body EMS is used, we can expect this method to see the increasing use in high-performance sports.

    My comments:

    The above emphasis was mine.  This is one of my favorite review papers on electric muscle stimulation (EMS), along with it’s brother paper that emphasized specific EMS parameters found to be most effective at increasing strength and sports performance. What’s interesting is that, like exercise, the principles between sports performance and physical therapy are almost identical. This paper should be a must-read for physical therapists, as electric stimulation seems clinically out of fashion (with dry needling for whatever reason being the latest fad). Ironically, the science, technology, effectiveness, and inexpensiveness of EMS have never been better. For athletes and patients, trying is usually immediately believing. Still, you need to be set up on a machine that can be programmed to proper parameters, using large comfortable electrodes, and you need to have a physical therapist who knows what parameters to use (here they are). Admittedly being hooked up to a circa 1990s TENS machine, or the typical physical therapy floor model combo machine with ultrasound, is a bit of a yawner. I’ll have to do an upcoming blog on what specific machines I like and don’t, because with electric stimulation technology you don’t always get what you pay for. The good news is that if you know what you are looking for, you can get a lot for a little.

    I should point out that while the abstract in the above paper talks about whole-body EMS being time efficient, the paper itself describes whole-body EMS as less effective at increasing performance than localized EMS (and this agrees with the studies I have read as well).  Otherwise the abstract is a pretty good summary of the paper.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Fibromyalgia Pain Decreased 30% with TENS and Exercise

    Effectiveness of high-frequency transcutaneous electrical nerve stimulation at tender points as adjuvant therapy for patients with fibromyalgia. Eur J Phys Rehabil Med. 2013 Apr;49(2):197-204. Carbonario F, Matsutani LA, Yuan SL, Marques AP.

    Abstract
    BACKGROUND:
    Fibromyalgia is a chronic pain syndrome associated with sleep disorders, fatigue and psychological symptoms. Combinations therapies, such as electrotherapy and therapeutic exercises have been used in the clinical practice.
    AIM:
    To assess the efficacy of high-frequency transcutaneous electrical nerve stimulation (TENS) as an adjuvant therapy to aerobic and stretching exercises, for the treatment of fibromyalgia.
    DESIGN:
    Controlled clinical trial.
    SETTING:
    Unit of rehabilitation of a public hospital.
    POPULATION:
    Twenty-eight women aged 52.4±7.5 years, with fibromyalgia.
    METHODS:
    A visual analogue scale measured pain intensity; tender points pain threshold, by dolorimetry; and quality of life, by the FibromyalgiaImpact Questionnaire. All subjects participated in an eight-week program consisting of aerobic exercises, followed by static stretching of muscle chains. In TENS group, high-frequency (150 Hz) was applied on bilateral tender points of trapezium and supraspinatus.
    RESULTS:
    TENS group had a greater pain reduction (mean change score=-2.0±2.9 cm) compared to Without TENS group (-0.7±3.7 cm). There was a difference between mean change scores of each group for pain threshold (right trapezium: 0.2±1 kg/cm² in TENS group and -0.2±1.2 kg/cm² in Without TENS group). In the evaluation of clinically important changes, patients receiving TENS had relevant improvement of pain, work performance, fatigue, stiffness, anxiety and depression compared to those not receiving TENS.
    CONCLUSION:
    It has suggested that high-frequency TENS as an adjuvant therapy is effective in relieving pain, anxiety, fatigue, stiffness, and in improving ability to work of patients with fibromyalgia.
    CLINICAL REHABILITATION IMPACT:
    High-frequency TENS may be used as a short-term complementary treatment of fibromyalgia.

    My Comments:
    Pain in the TENS group decreased 30% from 7.7/10 to 5.4 which I would say is good but not great, while the exercise only group pain decreased 13%. Tender point sensitization decreased only in the TENS group, indicating that the TENS is decreasing central sensitization which is a primary finding in fibromyalgia. Ability to work also increased 22% in the TENS group compared to 10% in the exercise only group. Fatigue improved 19% in the TENS group compared to 7% in the exercise only group. Anxiety improved 15% in the TENS group compared to 7% in the exercise only group. Depression improved about equal 18% and 19% in the TENS and exercise only group respectively. I think there is still a lot of optimizing to do with the TENS protocol which in this study was still relatively weak compared to my preferred EMS settings. Overall it provides additional evidence that electric stimulation is beneficial in chronic pain conditions and should be part of the patients physical therapy program.
    TENS parameters of this study were:

    • Waveform: not given
    • Rate: 150 Hz
    • Pulse duration: 150 uS
    • Treatment duration and frequency: 30 minutes per day, days per week not specified, 8 weeks total
    • Pulse amplitude: not specified but increased as tolerated to get a strong but comfortable sensation without muscle contraction
    • Duty cycle: continuous
    • Electrode placement: 4 electrodes placed over bilateral tender points of trapezium and supraspinatus

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Total Knee Replacement: More than 85% Last at Least 20 Years

    What is the evidence for total knee arthroplasty in young patients?: a systematic review of the literature. Clin Orthop Relat Res. 2011 Feb;469(2):574-83. Keeney JA1, Eunice S, Pashos G, Wright RW, Clohisy JC.

    Abstract
    BACKGROUND:
    TKA is commonly performed to treat advanced inflammatory and degenerative knee arthritis. With increasing use in younger patients, it is important to define the best practices to enhance clinical performance and implant longevity.
    QUESTIONS/PURPOSES:
    We systematically reviewed the literature to assess: (1) how TKAs perform in young patients; (2) whether the TKA is a durable procedure for young patients, and (3) what guidance the literature outlines for TKA in young patients.
    METHODS:
    We searched the literature between 1950 and 2009 for all studies reporting on TKAs for patients younger than 55 years that documented clinical and radiographic assessments with a minimum 2-year followup. Thirteen studies, reporting on 908 TKAs performed for 671 patients, met these criteria.
    RESULTS:
    Mean Knee Society clinical and functional scores increased by 47 and 37 points, respectively. Implant survivorship was reported between 90.6% and 99% during the first decade and between 85% and 96.5% during the second decade of followup. The literature does not direct specific techniques for TKA for young patients.
    CONCLUSIONS:
    TKA provides surgeon-measured clinical and functional improvements with a moderate increase in second-decade implant failures. Improvements in study design and reporting will be beneficial to guide decisions regarding implant selection and surgical technique.
    LEVEL OF EVIDENCE:
    Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

    My comments:

    So according to the above review, it’s hard to say exactly how long a new knee will last, but data indicates somewhere between 90-99% last at least 10 years and 85-96.5% last at least 20 years.

    As a physical therapist I can do a lot with a number of arthritic knees to lessen pain and increase strength and function. However, there is a point where even the best exercises cause more pain than they are worth. Once a patient starts curtailing their activity to avoid knee pain they begin a downward spiral of lost overall fitness combined with overworking their other leg, which then becomes arthritic and weaker as well. I’ve had some patients who would clearly benefit from a joint replacement but were apprehensive about doing so. When I ask why, they say someone told them the new knee will only last 10 years. I’m not sure if that meme ever had any basis in reality; I’ve rehabilitated a lot of total knees and I really don’t see very many revisions, and it’s even less likely true now with newer and better quality knee components.

    I tell my patients that if their knee arthritis is really holding them back from physical activity they should probably get it replaced. If you wait too long inactivity will make the rest of the body fall apart, which could include things as bad as heart attacks and strokes. So while I don’t think anyone should rush into the procedure, I think a lot of people put it off for too long. Besides enduring the pain and health problems from inactivity, weight gain from inactivity makes you a higher risk for surgery with much larger risk of serious complications. In fact a number of my cardiovascular patients, when being seen for overall function, gait training and balance, often have REALLY bad knees and/or hip arthritis that they probably should have had replaced 20 years ago, but now they are poor surgical candidates and no doctor will perform the surgery.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Fibromyalgia Improved Immediatley with TENS

    Transcutaneous electrical nerve stimulation reduces pain, fatigue and hyperalgesia while restoring central inhibition in primary fibromyalgia. Pain. 2013 Nov;154(11):2554-62. Dailey DL, Rakel BA, Vance CG, Liebano RE, Amrit AS, Bush HM, Lee KS, Lee JE, Sluka KA.

    Abstract
    Because transcutaneous electrical nerve stimulation (TENS) works by reducing central excitability and activating central inhibition pathways, we tested the hypothesis that TENS would reduce pain and fatigue and improve function and hyperalgesia in people with fibromyalgia who have enhanced central excitability and reduced inhibition. The current study used a double-blinded randomized, placebo-controlled cross-over design to test the effects of a single treatment of TENS with people with fibromyalgia. Three treatments were assessed in random order: active TENS, placebo TENS and no TENS. The following measures were assessed before and after each TENS treatment: pain and fatigue at rest and in movement; pressure pain thresholds, 6-m walk test, range of motion; 5-time sit-to-stand test, and single-leg stance. Conditioned pain modulation was completed at the end of testing. There was a significant decrease in pain and fatigue with movement for active TENS compared to placebo and no TENS. Pressure pain thresholds increased at the site of TENS (spine) and outside the site of TENS (leg) when compared to placebo TENS or no TENS. During active TENS, conditioned pain modulation was significantly stronger compared to placebo TENS and no TENS. No changes in functional tasks were observed with TENS. Thus, the current study suggests TENS has short-term efficacy in relieving symptoms of fibromyalgia while the stimulator is active. Future clinical trials should examine the effects of repeated daily delivery of TENS, similar to the way in which TENS is used clinically on pain, fatigue, function, and quality of life in individuals with fibromyalgia.

    My comments:

    In practical terms it’s not exactly breaking news, as just about every fibromyalgia patient I see already owns one or more TENS machines.  However, this is an interesting study because it showed immediate positive effects on central sensitization.  After my last blog on central sensitization and chronic pain, I looked up more research with regards to the effects of TENS, since central sensitization sounded like the opposite effect of gate control theory.  TENS was designed specifically to make use of gate control theory to reduce pain, and as expected, here’s a study that showed a single treatment of TENS decreased pain, fatigue, and hyperalgesia (pain sensitivity) by lessening central sensitization/restoring central inhibition of pain.

    Parameters in this study were:

    • Waveform: not given
    • Rate: 100 Hz
    • Pulse duration: 200 uS
    • Treatment Duration: 30 minutes
    • Pulse amplitude: maximum tolerable without pain (average 39.93 mA
    • Duty cycle: continuous

    The researchers agree they need to test for cumulative improvements over time. They also noted that they did not decrease pain at rest but did decrease pain with movement. They recommended wearing the device while exercising, which sounds reasonable. While TENS had positive effects in this study, in my physical therapy clinic I notice even greater reductions in pain and improvements in function with EMS parameters (electric stimulation parameters designed to increase muscle strength), rather than with TENS parameters.  The benefits of EMS over TENS parameters (even for pain) are great enough that I always search for research on EMS first for a given condition. Unfortunately with fibromyalgia I have yet to find any studies, so you have to take what you can get. Anecdotally though, EMS works so much better that I almost never use TENS anymore.  The difference between them is only a few button pushes on the same machine anyway.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Central Sensitization and Chronic Pain

    Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011 Mar;152(3 Suppl):S2-15. Woolf CJ. [FREE FULL TEXT]

    Abstract
    Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity.

    My comments:
    This paper isn’t a study but is a review of 279 other papers regarding the concept of central sensitization. The idea, which this paper shows is well established in research, is that certain types of painful stimuli that travel up the nervous system make it more sensitive to future painful stimuli. Thus, making what should be a normal touch sensation a painful one. This is often seen in patients with fibromyalgia. The mechanism of action described in the paper sounds a lot like gate control theory in reverse. This seems to be associated with A LOT of chronic pain conditions where pain felt seems to exceed apparent physiological damage.

    Conditions described in this paper include rheumatoid arthritis, osteoarthritis, temporomandibular disorders, fibromyalgia, headache, neuropathic pain, complex regional pain syndrome, post surgical pain and visceral pain hypersensitivity syndromes. What the paper also discussed, and what I have often seen in my physical therapy practice, is that these conditions while seemingly unrelated happen often in the same individuals. This indicates a likely common cause or contributor.

    The author spoke about numerous studies using “brief (10-20 s) , low frequency (1-10 Hz) bursts of action potentials into the CNS” which increased synaptic efficiency of nociceptors in the dorsal horn of the spinal cord for tens of minutes afterwards.  At this point I’m not sure how this relates to gate control theory, but it might indicate low rate TENS isn’t ideal if your goals is to reduce central sensitization.  In my observation patients find higher rate TENS and EMS more comfortable and more effective at decreasing pain, and perhaps this is part of the reason why.  I’ll have to research this area further.

    Unfortunately, the paper says there is still a lot to be learned about genetic and environmental factors that increase the risk of development central sensitization, or exactly what triggers and sustains it in particular patients. The paper is definitely a good read for physical therapists working with chronic pain patients who might otherwise think their patients are malingerers, lazy, exaggerating their symptoms, have psychosomatic problems, or just don’t want to get better. Instead, central sensitization is a real neurobiological phenomenon.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Neck Pain/Tender Points Reduced Most by Strength Exercise

    Effect of long-term neck muscle training on pressure pain threshold: a randomized controlled trial. Eur J Pain. 2005 Dec;9(6):673-81. Ylinen J, Takala EP, Kautiainen H, Nykänen M, Häkkinen A, Pohjolainen T, Karppi SL, Airaksinen O.

    Abstract
    Muscle tenderness has been measured in several studies to evaluate effectiveness of treatment methods, but only short-term results have been reported so far. The aim of the present study was to evaluate the long-term effects of two different muscle training methods on the pressure pain threshold of neck muscles in women with neck pain. Altogether 180 woman with chronic, non-specific neck pain were randomized into three groups: neck muscle endurance training, neck muscle strength training and control groups. The main outcome measures included pressure pain threshold measurement at six muscle sites and on the sternum. Neck pain was assessed by a visual analogue scale (VAS). At the 12-month follow-up statistically significantly higher pressure pain threshold values were obtained in both training groups at all muscle sites compared to the baseline, while no significant change occurred in the controls. Significantly higher changes in pressure pain threshold were detected at all six sites in the strength training group and at four out of six sites in the endurance training group compared to the control group. This is the first study to show an increase in pressure pain thresholds as a result of long-term muscle training. A decrease in neck pain was associated with reduced pressure pain sensitivity in neck muscles, showing that the pressure pain threshold may be a useful outcome measure of the effectiveness of neck muscle rehabilitation.

    My comments
    I think this study was done on the same population as the one I blogged on previously (exact exercise program described there) where both strength and endurance training improved pain and ROM better than stretching alone. This study found a significant decrease in tender points in both the strength and endurance groups as compared to the stretching only control group. The strength group was a little better off than the endurance group.
    Quotes from the paper I found particularly interesting were as follows:

    “Our finding supports this earlier finding that stretching with light aerobic exercise does not seem to have much effect on pressure pain threshold values.”

    “Emotions like fear may exacerbate pain (Keefe et al., 2004). Fear can be diminished or blanked out by consciously exercising structures that have been associated with pain (Klaber et al., 2004).

    The latter quote is interesting enough that I am going to order both the Keefe and Klaber references which might make for a good future physical therapy blog.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Neck Pain Immediately Reduced After Strength and Posture Exercise

    Specific therapeutic exercise of the neck induces immediate local hypoalgesia. J Pain. 2007 Nov;8(11):832-9. Epub 2007 Jul 19. O’Leary S, Falla D, Hodges PW, Jull G, Vicenzino B.

    Abstract
    This study compared the effect of 2 specific cervical flexor muscle exercise protocols on immediate pain relief in the cervical spine of people with chronic neck pain. In addition, the study evaluated whether these exercise protocols elicited any systemic effects by studying sympathetic nervous system (SNS) function and pain at a location distant from the cervical spine. Participants were randomly allocated into either a cranio-cervical flexion (CCF) coordination exercise group (n = 24) or a cervical flexion (CF) endurance exercise group (n = 24). Measures of pain and SNS function were recorded immediately before and after a single session of the exercise interventions. Pain measures included visual analogue scale (VAS) ratings ofneck pain at rest and during active cervical motion and pressure pain threshold (PPT) and thermal pain threshold (TPT) recordings over the cervical spine and at a remote site on the leg. Measures of SNS function consisted of blood flow, skin conductance, skin temperature, heart rate, and blood pressure. Immediately after 1 session of exercise, there was a reasonably sized increase of 21% (P < .001, d = 0.88) and 7.3% (P = .03, d = 0.47) in PPT locally at the neck for the CCF exercise and the CF exercise, respectively. There were no changes in local neck TPT with either exercise. Pressure pain threshold and TPT at the leg and SNS did not change after exercise. Only the CCF exercise demonstrated a small improvement in VAS ratings during active movement (change on 10-cm VAS: CCF, 0.42 cm (P = .04). This study shows that specific CCF therapeutic exercise is likely to provide immediate change in mechanical hyperalgesia local to the neck with translation into perceived pain relief on movement in patients with chronic neck pain.
    PERSPECTIVE:
    This study showed an immediate local mechanical hypoalgesic response to specific exercise of the cervical spine. Understanding the pain-relieving effects of exercise will assist the clinician in prescribing the most appropriate exercise protocols for patients with chronic neck pain.

    My comments:
    Hypoalgesia is a good five dollar word that means there was a decrease in pain and pain sensitivity immediately after the exercises performed in neck pain sufferers. It’s interesting seeing this put into a study. When I treat my physical therapy patients for neck pain with a largely exercise-based approach, they often report their pain levels decreasing from the beginning to the end of the workout. This decrease in pain happens before the application of EMS, which is my preferred modality for pain. This paper reviewed a number of others discussing “exercise induced hypoalgesia” which seems to be a hot area in research right now.

    The exercises used were a supine neck flexion hold, where you lay on your back and hold your head no more than 2 cm off the table (which is an exercise I like). They did 3 sets of 10 reps, each rep with a 3 second hold and 2 second rest with 30 seconds between. Resistance was added to the forehead as needed. The other exercise was a supine (lying on your back) chin tuck, where you attempted to bring your chin toward the chest while keeping the back of your head flat on the mat. The chin tuck was held for 10 seconds with 10 seconds rest in between for 10 reps.

    Both exercises worked to decrease pain, but the chin tuck exercise worked better.  I imagine the difference might be due to the chin tuck increasing space for the spinal cord and nerves exiting the cervical spine, and perhaps it having a more immediate effect on improving posture once completed. The improved posture also increases space for the spinal cord and nerves exiting the cervical spine after the exercise so it’s win-win.  The other exercise would do more to increase cervical flexor strength and endurance, which would likely lead to gains further down the road. However, it does not immediately lessen stresses on cervical structures in the same way the chin tuck does. So which exercise should be in your physical therapy or home exercise program for neck pain? Probably both, along with a number of others. This was a great study overall; I learned something.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Strength Training with Chronic Neck Pain Improves Quality of Life

    Effect of neck strength training on health-related quality of life in females with chronic neck pain: a randomized controlled 1-year follow-up study. Health Qual Life Outcomes. 2010 May 14;8:48. Salo PK, Häkkinen AH, Kautiainen H, Ylinen JJ.

    Abstract BACKGROUND: Chronic neck pain is a common condition associated not only with a decrease in neck muscle strength, but also with decrease in health-related quality of life (HRQoL). While neck strength training has been shown to be effective in improving neck muscle strength and reducing neck pain, HRQoL among patients with neck pain has been reported as an outcome in only two short-term exercise intervention studies. Thus, reports on the influence of a long-term neck strength training intervention on HRQoL among patients with chronic neck pain have been lacking. This study reports the effect of one-year neck strength training on HRQoL in females with chronic neck pain. METHODS: One hundred eighty female office workers, 25 to 53 years of age, with chronic neck pain were randomized to a strength training group (STG, n = 60), endurance training group (ETG, n = 60) or control group (CG, n = 60). The STG performed high-intensity isometric neck strengthening exercises with an elastic band while the ETG performed lighter dynamic neck muscle training. The CG received a single session of guidance on stretching exercises. HRQoL was assessed using the generic 15D questionnaire at baseline and after 12 months. Statistical comparisons among the groups were performed using bootstrap-type analysis of covariance (ANCOVA) with baseline values as covariates. Effect sizes were calculated using the Cohen method for paired samples. RESULTS: Training led to statistically significant improvement in the 15D total scores for both training groups, whereas no changes occurred for the control group (P = 0.012, between groups). The STG improved significantly in five of 15 dimensions, while the ETG improved significantly in two dimensions. Effect size (and 95% confidence intervals) for the 15D total score was 0.39 (0.13 to 0.72) for the STG, 0.37 (0.08 to 0.67) for the ETG, and -0.06 (-0.25 to 0.15) for the CG. CONCLUSIONS: One year of either strength or endurance training seemed to moderately enhance the HRQoL. Neck and upper body training can be recommended to improve HRQoL of females with neck pain if they are motivated for long-term regular exercise.

    My comments: This is further confirmation that strength training for women with chronic neck pain is beneficial. Subjects in the strength training group did a single set of 15 reps at 80% of their maximum isometric strength level in 4 directions, forward, backward, right and left.  Max isometric strength was updated at 2 and 6 months.  The neck was kept neutral as they moved against the band with the hips and a force device was attached to ensure 80% force.  The time each repetition was held was not given.  In addition they did one set each of basic upper body free weights exercises including shrugs, presses, curls, bent over flys, and pullovers for 15 reps with the highest weight possible, increasing the weight when they could get 20 reps. While this is another study showing that strengthening is more effective than stretch for the treatment of chronic neck pain, the improvements were significant but not exceptional. The reason is that with spine injuries in particular, exercise while beneficial is not the entire answer. Motor control, ergonomics and postural alignment are all part of recovery, and part of my physical therapy programs for neck pain. In addition I find electric muscle stimulation very effective at acutely decreasing pain while further increasing muscle strength and endurance just as well as it does with low back pain, thus complementing the active exercise, motor control and postural improvements.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Greater EMS Rate Causes Greater Blood Flow with Peripheral Artery Disease

    Calf muscle stimulation with the Veinoplus device results in a significant increase in lower limb inflow without generating limb ischemia or pain in patients with peripheral artery disease. J Vasc Surg. 2013 Mar;57(3):714-9. Abraham P1, Mateus V, Bieuzen F, Ouedraogo N, Cisse F, Leftheriotis G.

    Abstract
    OBJECTIVE:
    Increase in arterial inflow to the lower limbs is important to obtain functional improvement in peripheral artery disease (PAD) patients with claudication. The aim of this study was to assess the effect of electrical stimulation of calf muscles on arterial inflow and tissue oxygen content in PAD in the area of stimulation.
    METHODS:
    Fifteen adult patients [mean (standard deviation) age, 62 (12 ) years; height, 165 (8)cm; weight, 76 (13) kg; lowest ankle-brachial index 0.66 (0.19)] with stable arterial claudication were recruited. All patients performed a treadmill test (3.2 km/h, 10% slope) associated with a transcutaneous oximetry test expressed as decrease from rest of oxygen pressure (DROP) index values (calf changes minus chest changes from rest) with a maximum walking distance (median [25th/75th percentiles]) of 295 [133-881] m. The DROP index on the symptomatic side was -25 [-18/-34] mm Hg. On another day the patients underwent electrical stimulation in the seated position on the leg that was the most symptomatic on the treadmill. After resting values were recorded, the gastrocnemius was stimulated for 20minutes at increasing contraction rates at 5-minute steps of 60, 75, 86, and 100bpm on the most symptomatic side. Arterial blood inflow with duplex Doppler ultrasound scanning of the femoral artery, DROP transcutaneous oxygen pressure value, and oxygen concentration (O2Hb) from the near-infrared spectroscopic signal of the calf were recorded on both sides. Patients were instructed to report eventual contraction-induced pain in the stimulated calf. Results are given as mean (standard deviation) or median [25th/75th percentiles] according to distribution, and the level of statistical significance was set at P < .05 on two-tailed tests.
    RESULTS:
    Lower limb inflow (mL/min) was 64 [48/86] vs 63 [57/81] (P> .05) before stimulation, 123 [75/156] vs 57 [44/92] (P < .01) at 60bpm, 127 [91/207] vs 49 [43/68] (P < .01) at 75bpm, 140 [84/200] vs 57 [45/71] (P < .01) at 86bpm, and 154 [86/185] vs 55 [46/94] (P < .01) at 100bpm on the stimulated vs nonstimulated limb, respectively. No apparent decrease or significant leg difference was observed in DROP index or O2Hb values. None of the patients reported contraction-induced pain in the leg.
    CONCLUSIONS:
    Electrical stimulation of calf muscle with the Veinoplus device results in a significant increase of arterial inflow without measurable muscle ischemia or pain. Potential use of this device as an adjuvant treatment to improve walking capacity in PAD patients remains to be evaluated.

    My comments:

    • Parameters in this study were:
    • Waveform: symmetrical biphasic
    • Rate: 60 to 100 pulses per minute (pretty slow)
    • Pulse duration: modulated, up to 240 uS
    • Intensity: increased to a visible but comfortable contraction
    • Treatment time: 20 minutes
    • electrodes: larger 8 cm x 13 cm ovals placed laterally on gastrocnemius muscle bellies

    Not a lot of data with regards to function but they did note higher beats per minute (bpm) led to greater increases in LE bloodflow.  60 bpm caused 123 mL/min of bloodflow while 100 bpm increased bloodflow to 154 mL/min. However, 60 bpm is only 1 hz and 100 bpm is 1.67 Hz, so it is hard to say how that applies to most other electric stimulation units where the rate can reach well over 100 Hz.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Electric Stimulation and Peripheral Vascular Disease

    Chronic muscle stimulation improves ischaemic muscle performance in patients with peripheral vascular disease. Eur J Vasc Surg. 1994 Jul;8(4):419-22. Tsang GM1, Green MA, Crow AJ, Smith FC, Beck S, Hudlicka O, Shearman CP.

    Abstract
    There is currently no established treatment for intermittent claudication with proven long term benefit. Exercise classes have been shown to improve walking distance. Chronic electromyostimulation (CEMS) a method of stimulating skeletal muscle has effects on normal muscle which may also benefit claudicants. We investigated the effects of one month of CEMS on claudicants in a single blind placebo controlled study. Patients were randomised to either CEMS (treatment) or transcutaneous nerve stimulation (TENS) placebo. The effects of the two modalities were assessed using the conventional measures of claudicating distance (CD), maximum walking distance (MWD), ankle-brachial pressure index (ABPI) and pressure recovery time (PRT). Muscle performance was assessed by the fatigue index (FI) a technique determining the decrease in ischaemic muscle response to repeated contraction. After 4 weeks treatment the CEMS group showed significant improvements in their median CD (88 to 111) and MWD (118 to 158); this was not seen in the control group. Muscle performance also increased significantly during the 4 weeks of treatment in the CEMS group but not in the control group. These changes were not maintained after CEMS was stopped. This pilot study suggests that CEMS may well have a role to play in the treatment of intermittent claudication though a number of further studies need to be undertaken.

    My comments:
    This is an older study that found benefit of electric stimulation for intermittent claudication. As I think about its capabilities for a potential application I often find decades old research showing considerable benefit that seems to get lost in time, which is almost funny as all on pubmed.com.

    • Electric stimulation parameters used in this study were:
    • Frequency: 8 Hz
    • Pulse duration: 350 uS
    • Amplitude: “maximum tolerable”
    • Two electrodes placed over the “anterior tibial” and “poplitial” nerves, which is a little vague (a photo would have been nice)
    • Frequency and duration: 20 minutes per day, 3 times per day for 4 weeks.

    Walking performance was measured on a treadmill at 3.5 kpm (2.17 mph) with a 10 degree grade, with pain free walking distance (PFWD) increased 26% and maximal walking distance (MWD) improved 34%. While the results were better in the electric stimulation group than the control group, they weren’t a lot better, and by 4 weeks after treatment cessation the differences had largely disappeared. The latter I would expect and I think continued electric muscle stimulation and exercise is necessary for continued health. I also think the protocol used here is likely not optimal, though a similar protocol was used more recently (2004) with better results.  However the difference might be in electrode placement as in the 2004 study the electrodes were placed over the triceps surae motor point and muscle belly.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Electric Muscle Stimulation Helps Rheumatoid Arthritis

    Neuromuscular electrical stimulation and volitional exercise for individuals with rheumatoid arthritis: a multiple-patient case report. Physical Therapy. 2007 Aug;87(8):1064-77. Piva SR1, Goodnite EA, Azuma K, Woollard JD, Goodpaster BH, Wasko MC, Fitzgerald GK.

    Abstract
    BACKGROUND AND PURPOSE:
    Muscle atrophy is common in patients with rheumatoid arthritis (RA). Although neuromuscular electrical stimulation (NMES) is a viable treatment for muscle atrophy, there is no evidence about the use of NMES in patients with RA. The purposes of this multiple-patient case report are: (1) to describe the use of NMES applied to the quadriceps femoris muscles in conjunction with an exercise program in patients with RA; (2) to report on patient tolerance and changes in lean muscle mass, quadriceps femoris muscle strength (force-producing capacity), and physical function; and (3) to explore how changes in muscle mass relate to changes in quadriceps femoris muscle strength, measures of physical function, and patient adherence.
    CASE DESCRIPTION:
    Seven patients with RA (median age=61 years, range=39-80 years) underwent 16 weeks of NMES and volitional exercises. Lean muscle mass and strength of the quadriceps femoris muscle and physical function were measured before and after treatment.
    OUTCOMES:
    One patient did not tolerate the NMES treatment, and 2 patients did not complete at least half of the proposed treatment. Patients who completed the NMES and volitional exercise program increased their lean muscle mass, muscle strength, and physical function.
    DISCUSSION:
    Because of the small sample, whether NMES combined with exercises is better than exercise alone or NMES alone could not be determined. However, the outcomes from this multiple-patient case report indicate that NMES is a viable treatment option to address muscle atrophy and weakness in patients with RA. Strategies to increase tolerance and adherence to NMES are warranted.QUOTE

    FROM CONCLUSION:
    “…we believe that the changes in quadriceps femoris lean muscle mass observed in this report were more likely due to the NMES program than to the volitional exercises because our volitional exercise program was not of high intensity like the studies that have shown increases in lean muscle mass.”

    My comments:

    This is an ideal situation for electric muscle stimulation: trying to maintain strength when active exercise might be too stressful, such as during an RA exacerbation. Improvements seem relatively similar to those shown with osteoarthritis and EMS.  The EMS parameters used in this study were:

    • Duty Cycle: 4 second ramp, 6 seconds on 50 seconds off
    • Hz: 75
    • Pulse duration: 250 uS
    • Amplitude: at maximum patient tolerance (38-90 mA)
    • Duration: 10-60 minutes working from 10 to 30 contraction over 2 weeks
    • Electrodes: 6.98 cm x 12.7cm placed on vastus lateralus proximally and vastus medialus medially.
    • Frequency: 16 weeks, with an average of 9 supervised sessions and 31 home sessions, averaging 2.5 treatments per week.

    I would use a longer pulse duration, higher Hz, shortened ramp, and set the on time to 10 seconds. That said, the parameters in this study sound reasonably decent. More electrodes on additional muscles would, I’m sure, lead to additional functional improvements, but the EMPI 300 model used in the study only has 2 channels. My preference is for 4 channel units like the EV-906 or Globus Genesy models simply because you can work more muscles at once either at home or in physical therapy.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • EMS Increases Circulation and Function with Severe PVD

    The influence of electrostimulation on the circulation of the remaining leg in patients with one-sided amputation. Angiology. 2002 May-Jun;53(3):329-35. Presern-Strukelj M1, Poredos P.

    Abstract
    The aim of the authors’ study was to investigate, in patients with one leg amputated, the influence of electrostimulation on the arterial circulation of the other lower limb and on the ability of a leg with deteriorated blood flow to perform work. The study encompassed 50 patients who were admitted to the rehabilitation center to obtain a leg prosthesis and learn to walk after amputation of 1 lower limb because of severe circulatory disturbance. The patients were randomly divided into 2 groups. The first group contained 25 patients treated with a standard exercise program for patients with limb amputation (control group, C). In this control group, according to the Fontaine’s classification of peripheral arterial occlusive disease (PAOD), 15 patients were in stage I and 10 patients were in stage II. In the second group, the electro stimulated (ES) group, there were also 25 patients that had the same rehabilitation program, to which electrostimulation of the gastrocnemius muscle of the remaining leg was added. In this group, 14 patients were in stage I, 10 patients were in stage II, and 1 patient was in stage III of PAOD. For electrostimulation, biphasic charge-balanced asymmetrical current stimuli with a pulse duration of 0.25 ms were used. The electrostimulation program consisted of 2 hours of electrostimulation per day for 8 weeks. Each patient was examined at the start of the rehabilitation program (examination I), at the end of the 8-week program (examination II) and at the end of a 1-year follow-up period (examination III). The effects of the treatment were followed using clinical examination, determination of the ankle-brachial index (ABI), and by measuring the partial oxygen pressure (TcPO2) on the skin surface of the diseased leg at rest and during exercise. After 8 weeks of treatment, in 3 patients of the ES group, claudication disappeared, and they thus moved from clinical stage II to stage I. In the control group, there were no changes in the clinical stages of PAOD. At the end of the observation period, 6 patients in group C and 5 patients in the ES group registered a progression of PAOD. During the observation period, 3 patients in group C and 1 patient in the ES group had below-knee amputations of the remaining leg (p<0.01). Perfusion pressures and ABI of investigated legs were comparable between groups and did not change during treatment. After 1 year of observation, there was a trend to ABI decrease in both groups. The capability of the diseased leg for performing work increased significantly during treatment only in the ES group. During treatment, TcPO2 at rest on the dorsum of the foot increased nonsignificantly in the ES group but in group C a trend of decrease in its value was indicated. After 8 weeks of treatment, total and partial oxygen drop during exercise significantly decreased in the ES group; whereas, in group C, there was no significant change. During the 1-year observation period, these effects of electrostimulation disappeared; however, fewer amputations in the ES group favor the presumption that this could be a positive effect of electrostimulation. The results of the authors’ study showed that electrostimulation improved oxygen delivery to a leg with disturbed arterial circulation and increased its work load capacity. The changes are probably caused by improvement of microcirculation.

    My comments:

    This is an older study, but I think it’s good because they use electric stimulation parameters that I’d expect to be pretty effective at increasing blood flow:

    • Duty cycle: 4 seconds on 4 seconds off
    • Pulse Rate: 40 Hz,
    • Pulse Duration: 250 uS
    • Pulse Amplitude: 30-50 mA to the point where they got slight muscle contractions
    • Frequency, Duration, Length of Treatment: 2 hours daily for 8 weeks.

    For this population I would have used a larger pulse duration, but I expect 4 on 4 off would do a lot to increase circulation and improve function in patients with significant peripheral vascular disease.  Their condition did decline after treatment was stopped, so it should probably be utilized permanently at home.  As used in this study, the electric stimulation could be easily performed and tolerated while watching TV, while walking around, or even sleeping. It would be interesting to know if the parameters in this study affected capillary density and growth factors as as found with lower intensity TENS type stimulation.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Electric Stimulation Increases Capillary Number and Oxygenation in Peripheral Vascular Disease

    Noninvasive augmentation of microvessel number in patients with peripheral vascular disease. J Vasc Surg. 2003 Dec;38(6):1309-12. Clover AJ, McCarthy MJ, Hodgkinson K, Bell PR, Brindle NP.

    Abstract
    OBJECTIVE:
    Therapeutic angiogenesis has great potential for the treatment of ischemic diseases. One possible route for noninvasive induction of microvessels has recently been suggested by the finding that subcontractile electrical stimulation induces increased vascularization in animals. The present study tests the ability of such stimulation to augment microvessel number in patients with peripheral vascular disease.
    DESIGN OF STUDY:
    Overall, 36 patients were randomly assigned to control (n = 12) and treatment (n = 24) groups. Patients in the treatment group received localized subcontractile electrical stimulation on the feet of their ischemic limbs for three 60-minute periods each day over a 6-week period. Microvessel density was determined by capillary microscopy before treatment, at 3 and 6 weeks during treatment, and 4 weeks after completion. Transcutaneous oxygen tension was also determined at this site.
    RESULTS:
    Microvessel density determined by capillary microscopy was significantly increased (1.25-fold, P <.005) during and after treatment in patients receiving electrical stimulation. Transcutaneous oxygen tension was similarly increased in the treated patients (1.24-fold, P <.05). No changes were observed in these parameters in untreated patients examined in parallel.
    CONCLUSION:
    Localized subcontractile electrical stimulation can increase microvessel density and tissue perfusion in patients with peripheral vascular disease.

    My comments:

    Interesting paper that certainly has likely has implications for how electric stimulation helps with peripheral vascular disease and intermittent claudication. The intensity was low in this study at 10 mA, at 8 Hz, with a 5×5 cm electrodes applied 3 times, 1 hour per day, every day for 6 weeks which is pretty light but with a fairly long application time. As the abstract shows microvessel density improved substantially as did oxygenation of the tissues. However tissue samples were taken directly adjacent the region of the electrodes so it is hard to know if such low level stimulation reaches deeper into muscle tissue which might be necessary to improve such conditions as intermittent claudication. The researchers thought the mechanism of action was due to electric stimulation increasing various growth factors including vascular endothelial growth factor (VEGF) and IGF-II.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Electric Stimulation for Intermittent Claudication

    Chronic transcutaneous electrical stimulation of calf muscles improves functional capacity without inducing systemic inflammation in claudicants. Eur J Vasc Endovasc Surg. 2004 Feb;27(2):201-9. Anderson SI, Whatling P, Hudlicka O, Gosling P, Simms M, Brown MD.

    Abstract OBJECTIVES: To assess whether electrical stimulation of ischaemic calf muscles in claudicants causes a systemic inflammatory response and to evaluate effects of its chronic application on muscle function and walking ability. DESIGN: Prospective randomised controlled trial of calf muscle stimulation. MATERIALS AND METHODS: Stable claudicants were randomised to receive either active chronic low frequency (6 Hz) motor stimulation (n=15) or, as a control treatment, submotor transcutaneous electrical nerve (TENS) stimulation (n=15) of calf muscles in one leg, 3 x 20 min per day for four weeks.  Leucocyte activation was quantified by changes in cell morphology, vascular permeability by urinary albumin:creatinine ratio (ACR), calf muscle function by isometric twitch contractions and walking ability by treadmill performance pre- and post-intervention. RESULTS: Acute active muscle stimulation activated leucocytes less (28% increase) than a standard treadmill test (81% increase) and did not increase ACR. Chronic calf muscle stimulation significantly increased pain-free walking distance by 35 m (95% CI 17, 52, P<0.001) and maximum walking distance by 39 m (95% CI 7, 70, P<0.05) while control treatment had no effect. Active stimulation prevented fatigue of calf muscles during isometric electrically evoked contractions by abolishing the slowing of relaxation that was responsible for loss of force. CONCLUSIONS: Chronic electrical muscle stimulation is an effective treatment for alleviating intermittent claudication which, by targeted activation of a small muscle mass, does not engender a significant systemic inflammatory response.

    My comments: Electric stimulation parameters of this study were:

    • Waveform: biphasic square wave
    • Rate: 6 Hz TENS
    • Pulse Duration: 250 uS
    • Amplitude: an intensity that elicits a visible, pain free muscle contraction
    • Electrode location: over the motor point and muscle belly of the triceps surae
    • Frequency and duration: 20 minutes performed 3 times per day for 4 weeks

    The stim was only done on the worse leg rather than both legs. They were tested by walking on a treadmill at 2.5 kph (1.55 mph) with a 10% incline. Improvements were reasonably impressive increasing pain free walking distance (PFWD) 108% and maximal walking distance (MWD) 50%, which isn’t bad for 4 weeks.

    • PFWD increase per week = 27%
    • MWD increase per week = 12.5%
    • PFWD increase per workout = 9%
    • MWD increase per workout = 4.2%

    Those increases are not that far different from what one gets with treadmill training and I would expect the treatments to be complementary.  I tried the TENS program like above on myself and my patients and thought it would help but I think you would get both increased strength and blood flow with a longer on and off time, 2 on 2 off (EMS pattern feels optimal to me) and I think the EMS current will better increase strength and likely decrease pain better at the same time. I would use a longer pulse width as well with the EMS, up to 450 uS if I had it available.  The control group in this study used a very light TENS pattern that did not cause muscle contraction and they had no improvement in function, and that’s what I would expect, it’s the electrically induced muscle contraction that is likely responsible the the improved function, which is why I would expect EMS with a higher intensity, longer muscle contraction and longer pulse with to be better still, though I think a short rest  is likely going to better improve circulation than you would get with some more classic strength EMS type protocols.

    [Update 4-28-16] I’ve been meaning to take back what I said about 2 second on 2 second off being optimal. I think 2 on 2 off would work but after doing my EMS for aerobics tests I think the 6 hz they used in the study to be nearly ideal. However in my experience 5 hz was slightly better. I still expect a pulse duration of 450 uS to be considerably better than the 250 uS used in the study simply because it will reach more muscle thus further increase circulation. This would be particularly important for those with nerve damage often accompanying intermittent claudication.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Low-Intensity Pain-Free Treadmill Exercise for Intermittent Claudication

    Benefits of low-intensity pain-free treadmill exercise on functional capacity of individuals presenting with intermittent claudication due to peripheral arterial disease.  Angiology. 2009 Aug-Sep;60(4):477-86. Barak S, Stopka CB, Archer Martinez C, Carmeli E.

    Abstract
    Patients with intermittent claudication due to peripheral arterial disease (PAD) experience muscle aching during walking secondary to ischemia.  The purpose of this study was to examine the effects of low-intensity pain-free exercise (LIPFE) on functional capacity of individuals with PAD.  A total of 12 participants with PAD underwent training on treadmill for 6 weeks, twice a week, for about 45 minutes. Outcome measures included walking distance (WDI), walking duration (WDU), mean walking rate (WR), estimated oxygen consumption (EVO(2)), metabolic equivalent (MET), estimated total energy expenditure (ETEE), and estimated rate of energy expenditure (EREE).  Mean improvement of WDI, WDU, and MWR were 104% (an addition of 1.0 km), 55% (an addition of 13.3 minutes), and 41% (0.9 km/h faster), respectively.  Mean improvement of EVO(2), MET, ETEE, and EREE, were 20%, 20%, 80%, and 20%, respectively.  In conclusion, it appears that LIPFE training is an effective intervention for individuals presenting with PAD.

    My comments:

    This program used a reasonably standard 5 point pain scale but added a 0.5 point, which meant “tiredness, heaviness, or tightness in the legs without pain” before level one which was mild pain.  The subjects aimed to walk with pain <1.0 on the scale. The exercise was done 3 times per week for 6 weeks with continuous walking averaging 24 minutes at first and working to 37 minutes at the end of the 6 weeks.  Rather than a form of intervals in the other program, this one was continuous exercise with the speed decreased if any pain was felt. Progress was made in walking distance, duration, and speed.  Speed on average increased from 2.2 kpm (1.3 mph) to 3.0 kpm (1.86 mph) which while meaningful is still pretty slow.  Improvements per week and workout are as follows:

    • Walking Distance / week = 17.5%
    • Walking Duration / week = 9.3%
    • Walking Speed / week = 13.7%
    • Walking Distance / workout = 9.7%
    • Walking Duration / workout = 3.1%
    • Walking Speed / workout = 2.3%

    The increases look reasonably good, however the patients started off at a very low rate and short distance. Even at the end of 6 weeks they were only walking 1.86 mph, which isn’t fast enough to safely get you across an intersection. Also, even with percents per week and workout it is difficult to compare to other studies with speed and duration all separated out. That’s why I still think the most objective measure would and should be the 6 minute walk test as both speed and endurance are taken into account, rather than trading off one for another.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Pain Free Treadmill Training for Intermittent Claudication?

    Experimental model of pain-free treadmill training in patients with claudication. Am J Phys Med Rehabil. 2005 Oct;84(10):756-62. Mika P, Spodaryk K, Cencora A, Unnithan VB, Mika A.

    Abstract
    OBJECTIVE:
    Treadmill training in claudication is often based on walking exercise to a pain threshold or longer to the maximum muscle pain of the lower limbs.  This kind of exercise may cause an inflammatory response. The purpose of this study was to determine whether pain-free treadmill training using walking exercise to 85% of the distance to onset of claudication pain can significantly improve pain-free walking distance in patients with intermittent claudication and to evaluate whether this kind of program may induce an inflammatory response leading to the progression of atherosclerosis.
    DESIGN:
    A total of 98 patients aged 50-70 yrs with stable intermittent claudication were randomized into a supervised treadmill training program or a comparison group.  Patients in the treatment group participated in 12 wks of supervised treadmill training.  We examined the effects of 12 wks of pain-free treadmill training on pain-free walking distance, total leukocyte count, neutrophil count, and microalbuminuria in patients with claudication.
    RESULTS:
    A total of 80 participants completed the program.  Exercise rehabilitation increased the time to onset of claudication pain by 119.2%, from 87.4 +/- 38 m to 191.6 +/- 94.8 m (P < 0.001).  There was no increase in total leukocyte count, neutrophil count, or microalbuminuria after 12 wks of treadmill exercise (P > 0.05)
    CONCLUSION:
    A pain-free training program can be used in the treatment of claudication as a low-risk program, increasing walking ability without potential harmful effects of ischemia-reperfusion injury.

    My comments:

    Most of the papers I have discussed earlier encouraged walking to various points of pain to treat intermittent claudication. The idea was that the pain brought on was a stress needed to force increased blood flow to the lower extremities which would later improve total and pain free walking distance.

    The protocol used here was to have patients walk at 2 mph at a 12 degree grade and find out the distance that pain comes on. Then patients would do the same, but only go to 85% of that distance, rest ~2 minutes and do it again for a total of 3 times in a session.  Training was performed 3 times per week for 12 weeks. Pain free walking distance (PFWD) was recalibrated once at 6 weeks.  PFWD improved 119%, while total distance and speed (beyond the 2 mph) were not measured.

    • PFWD increase per week = 9.92%
    • PFWD increase per workout = 3.31%

    Improvements look reasonably good and indicate that pain free walking has benefits, and not much less than some programs where patients did walk to a degree of pain.  This program might be idea for patients who might have a lesser tolerance for pain.  Interestingly the interval treadmill protocol with active rest is holding strong in first place with results per week and per workout.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Intermittent Claudication and the Importance of Supervision

    The Effect of Supervision on Walking Distance in Patients with Intermittent Claudication: A Meta-analysis. Eur J Vasc Endovasc Surg. 2014 Jun 10. pii: S1078-5884(14)00206-8. doi: 10.1016/j.ejvs.2014.04.019. [Epub ahead of print]  Gommans LN, Saarloos R, Scheltinga MR, Houterman S, de Bie RA, Fokkenrood HJ, Teijink JA.

    Abstract
    BACKGROUND:
    A number of reviews have reported the influence of exercise therapy (ET) for the treatment of intermittent claudication (IC). However, a complete overview of different types of ET is lacking. The aim of this meta-analysis was to study the effect of supervision on walkingcapacity in patients with IC. It was hypothesized that there was a positive treatment effect in relation to the intensity of supervision and improvement in walking capacity (i.e., a “dose-response” hypothesis).
    METHODS:
    A systematic search in the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases was performed. Only randomized controlled trials (RCTs) evaluating the efficacy of an ET in IC were included. Type of supervision, treadmill protocol, length of ET, total training volume, and change in walking distance were extracted. RCTs were categorised according to type of support: no exercise, walking advice, home-based exercise (HB-ET), and supervised exercise therapy (SET). A standardised mean difference between pre- and post-training maximalwalking distance (MWD) and pain-free walking distance (PFWD) was calculated for all subgroups at 6 weeks, and 3 and 6 months of follow up.
    RESULTS:
    Thirty studies involving 1406 patients with IC were included. The overall quality was moderate-to-good, although number of included patients varied widely (20-304). The intensity of supervision was directly related to MWD and PFWD. SET was superior to other conservative treatment regimens with respect to improvement in walking distances at all follow-ups. However, the difference between HB-ET and SET at 6 months of follow up was not significant.
    CONCLUSION:
    Supervised exercise therapy for intermittent claudication is superior to all other forms of exercise therapy. Intensity of supervision is related to improved walking distance.

    My comments:

    This a great paper that gives some pools data from 28 randomized controlled trials testing the effects of various walking programs and the effects of supervision. Advice to walk more had small benefits: home-based walking programs being slightly better, while supervised programs were better (well over twice as good when tested at 6 weeks, 3 months and 6 months). The authors also concluded that 12 weeks appears to be the optimal length of a supervised exercise program. Most of the gains in pain free walking distance and max walking distance occur in that period. After that point improvements appear to level off. So, the 12 week point might be an ideal time to transition to a home based walking program, and 12 weeks/3 months is what is recommended by the American Heart Association and TASC II.

    One thing I thought was interesting was in the conclusion they noted that the supervised exercise was more likely to be done on a treadmill, while the home programs were more likely to be done outdoors. I think it likely that this could be part of the reason for the improvement, because on a treadmill a person knows exactly how far and how fast they are walking. This likely keeps them honest and unlikely to slow down, since they have to push a button to do so. In outdoor walking one might gradually slow down and be completely unaware of it.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • McKenzie Method, Diagnosis No Better Than Treatment

    McKenzie lumbar classification: inter-rater agreement by physical therapists with different levels of formal McKenzie postgraduate training. Spine (Phila Pa 1976). 2014 Feb 1;39(3):E182-90.  Werneke MW, Deutscher D, Hart DL, Stratford P, Ladin J, Weinberg J, Herbowy S, Resnik L.

    Abstract
    STUDY DESIGN:
    Inter-rater chance-corrected agreement study.
    OBJECTIVE:
    The aim was to examine the association between therapists’ level of formal precredential McKenzie postgraduate training and agreement on the following McKenzie classification variables for patients with low back pain: main McKenzie syndromes, presence of lateral shift, derangement reducibility, directional preference, and centralization.
    SUMMARY OF BACKGROUND DATA:
    Minimal level of McKenzie postgraduate training needed to achieve acceptable agreement of McKenzie classification system is unknown.
    METHODS:
    Raters (N = 47) completed multiple sets of 2 independent successive examinations at 3 different stages of McKenzie postgraduate training (levels parts A and B, part C, and part D). Agreement was assessed with κ coefficients and associated 95% confidence intervals. A minimum κ threshold of 0.60 was used as a predetermined criterion for level of agreement acceptable for clinical use.
    RESULTS:
    Raters examined 1662 patients (mean age = 51 ± 15; range, 18-91; females, 57%). Data distributions were not even and were highly skewed for all classification variables. No training level studied had acceptable agreement for any McKenzie classification variable. Agreements for all levels of McKenzie postgraduate training were higher than expected by chance for most of the classification variables except parts A and B training level for judging lateral shift and centralization and part D training level for judging reducibility. Agreement between training levels parts A and B, part C, and part D were similar with overlapping 95% confidence intervals.
    CONCLUSION:
    Results indicate that level of inter-rater chance-corrected agreement of McKenzie classification system was not acceptable for therapists at any level of formal McKenzie postgraduate training. This finding raises concerns about the clinical utility of the McKenzie classification system at these training levels. Additional studies are needed to assess agreement levels for therapists who receive additional training or experience at the McKenzie credentialed or diploma levels.

    My comments:

    This new study on McKenzie method of physical therapy shows regardless of how well physical therapists are trained in the method, they don’t agree very well on a diagnosis. Robin McKenzie’s primary idea in the 1980s was that bending forward too much caused posterior migration of the nucleus in spinal discs leading to bulges, herniations, and subsequent neck and low back pain. That much has been confirmed by subsequent research, but a 2006 meta-analysis (a study that combines and comparing a number of smaller studies) found his method of treatment had little to no benefit in treating low back pain.

    This study found there was little agreement among physical therapists who took advanced training in McKenzie method as to which of McKenzie’s categories a patient fell into with regards to their particular type of low back pain. Regardless, I enjoyed McKenzie’s books and I think they should be read by all physical therapists specializing in low back or neck pain. However, as I commented in my earlier blog, I think he started off with a good idea that went too far. I often comment that his books are great if you only read the first half where he talks about avoiding spine flexion using lumbar support, and maybe doing some mild spine extension stretches. However, when he gets into end-range spine extension with overpressure and later advocates a return of lumbar flexion stretches I think he runs into problems. His treatment does not do anything to restore spine or extremity strength and endurance, which has been shown to reduce low back and neck pain.

    I always thought his evaluations were a bit drawn out, and often left a patient with low back or neck pain feeling worse after the first day, so I’m a little happy to see I’m not missing anything by not adopting the majority of them. I’ll do a future blog on Stuart McGill’s study where they found spine extension did sometimes help to reverse disc bulges, and how milder extension stretches can be implemented into a comprehensive low back rehabilitation program with positive effects, so maybe McKenzie will find at least limited redemption.  This does illustrate a pretty good caution about avoiding particular “methods” because eventually it’s founder dies, science moves on, and followers are left carrying on an outdated legacy.

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

  • Strength Training and Intermittent Claudication

    Strength training increases walking tolerance in intermittent claudication patients: randomized trial. J Vasc Surg. 2010 Jan;51(1):89-95.  Ritti-Dias RM, Wolosker N, de Moraes Forjaz CL, Carvalho CR, Cucato GG, Leão PP, de Fátima Nunes Marucci M.

    Abstract
    OBJECTIVE:
    To analyze the effects of strength training (ST) in walking capacity in patients with intermittent claudication (IC) compared with walking training (WT) effects.
    METHODS:
    Thirty patients with IC were randomized into ST and WT. Both groups trained twice a week for 12 weeks at the same rate of perceived exertion. ST consisted of three sets of 10 repetitions of whole body exercises. WT consisted of 15 bouts of 2-minute walking. Before and after the training program walking capacity, peak VO(2), VO(2) at the first stage of treadmill test, ankle brachial index, ischemic window, and knee extension strength were measured.
    RESULTS:
    ST improved initial claudication distance (358 +/- 224 vs 504 +/- 276 meters; P < .01), total walking distance (618 +/- 282 to 775 +/- 334 meters; P < .01), VO(2) at the first stage of treadmill test (9.7 +/- 2.6 vs 8.1 +/- 1.7 mL.kg(-1).minute; P < .01), ischemic window (0.81 +/- 1.16 vs 0.43 +/- 0.47 mm Hg minute meters(-1); P = .04), and knee extension strength (19 +/- 9 vs 21 +/- 8 kg and 21 +/- 9 vs 23 +/- 9; P < .01). Strength increases correlated with the increase in initial claudication distance (r = 0.64; P = .01) and with the decrease in VO(2) measured at the first stage of the treadmill test (r = -0.52; P = .04 and r = -0.55; P = .03). Adaptations following ST were similar to the ones observed after WT; however, patients reported lower pain during ST than WT (P < .01).
    CONCLUSION:
    ST improves functional limitation similarly to WT but it produces lower pain, suggesting that this type of exercise could be useful and should be considered in patients with IC.

     My comments:

    If you just read the abstract you would come away from this study with the impression that strength training is just as good as treadmill training for intermittent claudication.
    The weight training group used an 8 machine exercise protocol based working the total body 3 sets of 10 reps each which is fine enough. However both the weight training program, and the walking program (2 minutes on, 2 minutes off, for 60 minutes, attempting to get claudication the last 30 seconds of each interval), which to me sounds a bit dubious and not optimal for either. In both groups they wanted 60 minutes of total workout time, with 30 minutes of that time being rest in both groups and exercise was done 2 days per week for 12 weeks. While both groups improved neither group improved that much on a percent basis. Pain free walking distance (PFWD) improved 41% in the strength group and 37% in the treadmill group, while maximum walking distance (MWD) improved 25% in the strength group and 37% in the treadmill group. If I do the match per week and per workout improvements were as follows:

    • Strength PFWD/week = 3.4%
    • Strength MWD/week =2.1%
    • Strength PFWD/workout = 1.7%
    • Strength MWD/workout = 1.0%
    • Treadmill PFWD/week = 3.1%
    • Treadmill MWD/week = 3.1%
    • Treadmill PFWD/workout = 1.5%
    • Treadmill MWD/workout = 1.5%

    So neither the strength nor treadmill increases in walking distance were anything close to the improvements seen in either conventional walk/passive rest or walk/active rest protocols of other studies. Also I don’t think it was a great idea for the authors to try and equate effort between strength and treadmill programs and they would have done better to just use the best strength training program they could (with intensity based on repetition maximums) and compared that to the best walking program, rather than make up their own for each. Still I think it’s good that they found strength training did help improve walking distance and for patients with peripheral neuropathy who are particularly weak I think it would be an especially important part of their treatment.  Also this study noted that the strength training group had 50% less pain, which sounds great, but when you look at the specific data that meant pain during exercise was a 1.5/10 during strength training vs. 3/10 during treadmill training, which isn’t of that much practical significance.  

    Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

    Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.